Risk factors for manifestations of frailty in hospitalized older adults: A qualitative study

Abstract Aims To explore the experiences of older people and ward staff to identify modifiable factors (risk factors) which have the potential to reduce development or exacerbation of manifestations of frailty during hospitalization. To develop a theoretical framework of modifiable risk factors. Design Qualitative descriptive study. Methods Qualitative interviews with recently discharged older people (n = 18) and focus groups with ward staff (n = 22) were undertaken between July and October 2019. Data were analysed using directed content analysis. Results Themes identified related to attitude to risk, communication and, loss of routine, stimulation and confidence. Using findings from this study and previously identified literature, we developed a theoretical framework including 67 modifiable risk factors. Risk factors are grouped by patient risk factor domains (pain, medication, nutritional/fluid intake, mobility, elimination, infection, additional patient risk factors) and linked care management sub‐domains (including risk factors relating to the ward environment, process of care, ward culture or broader organizational set up). Many of the additional 36 risk factors identified by this study were related to care management sub‐domains. Conclusion A co‐ordinated approach is needed to address modifiable risk factors which lead to the development or exacerbation of manifestations of frailty in hospitalized older people. Risk assessment and management practices should not be duplicative and, should recognize and address modifiable risk factors which occur at the ward and organizational level. Impact Some older people leave hospital more dependent than when they come in and this is, in part, due to the environment and process of care and not just the severity of their presenting illness. Many of the risk factors identified need to be addressed at an organizational rather than individual level. Findings will inform a programme of research to develop and test a novel system of care aimed at preventing loss of independence in hospitalized older people.


| INTRODUC TI ON
Older people remain major users of hospital care; with people over 65 accounting for over 2 million unplanned hospital admissions and 40% of hospital bed days in England each year (Imison et al., 2012;Soong et al., 2015;The Health Foundation, 2018). Whilst some older people recover well from acute illness, others experience physical and functional decline, even when the illness which caused hospitalization is successfully treated (Covinsky et al., 2011;Lafont et al., 2011).
At particular risk are older people living with frailty; an abnormal health state characterized by poor physiological reserve (Clegg et al., 2013). In the 1960s, Bernard Isaacs described five 'Geriatric Giants'; key syndromes that commonly occur during acute illness in frail older people: falls, delirium, incontinence, immobility, loss of function (Isaacs, 1992). During hospitalization, older people are at increased risk of development or exacerbation of these five 'manifestations of frailty' (MoF). MoF are associated with poor outcomes in the short-term (e.g. in hospital morbidity, hospital-acquired infection, injurious falls and pressure ulcers) and in the longer term (e.g. increased likelihood of hospital readmission, reduced quality of life and increased levels of dependence; Bagshaw et al., 2014;Cunha et al., 2019;Hubbard et al., 2017;Keeble et al., 2019;Shin et al., 2016). Frail patients are at higher risk of poor outcome compared with non-frail patients, irrespective of illness severity (Pulok et al., 2020;Romero-Ortuno et al., 2016).

| Background
Decompensated frailty occurring during hospitalization may in part be due to the physiological stresses of acute illness (Clegg et al., 2013). However, there may also be modifiable factors encountered during periods of hospitalization which may contribute to the five MoF. Such factors can often be iatrogenic (i.e. related to the process or organization of hospital care). For example, even if able to ambulate, older people spend much of their time lying in bed or sitting during hospitalization, putting them at risk of immobility and functional decline (Brown et al., 2004;Pedersen et al., 2012). Modifiable factors also have significant overlap and interdependency in terms of their relationship to the development or exacerbation of MoF. For example, immobility (and it's risk factors) puts older people at higher risk of developing delirium (Ahmed et al., 2014); prescription of certain psychoactive medications or drugs with sedative properties can contribute to increased risk of both delirium and falls (Ahmed et al., 2014;Oliver et al., 2004). The relationship between risk factors and tendency to develop MoF is therefore complex, and specific to the individual.
The multidisciplinary care team (and in particular, nurses), has a key role in undertaking risk assessment and management procedures in hospitalized older adults (Han et al., 2021;Redley & Raggatt, 2017). In the United Kingdom, there are separate guidelines for the prevention and management of MoF in hospital e.g. delirium, falls, incontinence (National institute for Health & Care Excellence, 2019a, 2019b, 2019c. These guidelines may result in each MoF being considered in isolation from the others, despite overlapping risk factor profiles for each MoF. This can lead to duplicated assessment and overlapping care pathways. Furthermore, evidence from national audits suggests that risk assessment and management practices may be poorly implemented in practice (Royal College of Physicians, 2012Royal College of Psychiatrists, 2017). A co-ordinated approach to reduce the risk of functional decline in hospitalized older adults is needed. Such an approach should also co-ordinate with other procedures such as the Comprehensive Geriatric Assessment to ensure that care to reduce the risk of in hospital decline is considered as part of a broader, long-term, medical, social and functional needs assessment (Parker et al., 2018).
To address this, we undertook a programme of work as part of a National Institute for Health Research (NIHR) Project Development Grant (PDG, reference: RP-DG-0218-10001), 'Older People: a study to investigate maintaining Independence through a novel system of care (OPTIMISE), aimed at reducing the development or exacerbation of MoF'. To contribute towards the development of the intervention, we sought to identify and prioritize modifiable risk factors for the five MoF to be targeted by the system of care.
Initially we identified modifiable and non-modifiable risk factors for the five MoF through a scoping review of the literature informed by key guidelines. A summary of the risk factors identified are shown in Table 1. Whilst the scoping review provided a good starting point, we recognized that older people, their family members and ward staff may be in a unique position to identify features of ward environments, practices and organizational structures, not previously identified in the literature which might act as risk factors for MoF.
We sought to explore these experiences as part of the current study and to develop a theoretical framework of risk factors.

| Aims
To explore the experiences of older people and ward staff to identify modifiable factors (risk factors) which have the potential to reduce development or exacerbation of MoF during hospitalization (and physical and functional decline post-discharge). Using these experiences and informed by the literature, to then develop a theoretical framework of modifiable risk factors.

| Design
A qualitative descriptive design was chosen for this study which involved interviews with older people who had recently been discharged from hospital (study one) and focus groups with ward staff (study two; Kim et al., 2017;Lambert & Lambert, 2012;Sandelowski, 2000). We chose this design in line with our research aims which A copy of the topic guides is available in Supporting Information Files S1 and S2. Interviews and focus groups were audio recorded and transcribed verbatim. Fieldnotes were made to detail interruptions, distractions or additional thoughts on the topics discussed.
Fieldnotes provided additional contextual data to inform the coding and interpretation of transcripts. Transcripts/findings were not returned to participants for comment and/or correction. At the end of data collection, the research team were satisfied that the interviews and focus groups had reached a point where little new information was emerging.

| Ethical considerations
This study was approved by an NHS Research Ethics Committee in June 2019. All participants provided written informed consent. The right to withdraw from the study at any time without negative consequences was emphasized to all participants.

| Data analysis
Data were analysed using directed content analysis; an approach which is useful for validating or extending existing knowledge or theory (Assarroudi et al., 2018;Hsieh & Shannon, 2005

| Theoretical framework of modifiable risk factors
We developed a theoretical framework which draws on risk factors identified in the scoping review and from the qualitative study reported in this paper. The framework was developed logically to group risk factors together and also to specify proposed relationships between patient risk factors and related care management factors. Through discussions in the research team, risk factors were allocated to the predominant risk factor type (i.e. patient risk factors, linked care management risk factors and contextual risk factors) they were considered to belong to, though it is recognized that for some there maybe overlap between these. This was achieved by moving back and forth between the risk factors identified in the coded interview and focus group data and the theoretical framework and consideration of whether the risk factor was modifiable or not.

| Rigour
Procedures to ensure rigour were incorporated throughout the study. These are described in Table 2 with reference to Lincoln and Guba's trustworthiness criteria (credibility, transferability, dependability and confirmability) which are commonly used to describe rigour in qualitative research (Guba, 1981;Lincoln & Guba, 1985;Schwandt et al., 2007).

| FINDING S
A total of 26 patients and one carer provided consent to participate in an interview for the study. Nine patients dropped out of the study between providing consent and the interview being arranged. Reasons for dropout included; no longer wishing to participate, being unable to contact the patient or being unable to arrange the interview due to hospital readmission or the death of the patient. A total of 18 interviews were conducted with 17 patients and one carer (eight patients from site 1, nine patients and one carer at site 2). Table 3 shows an overview of patient characteristics. The mean age of patients was 79 (range 71-88) and the median CFS was 4 (range 2-7). All patient participants were of white ethnicity. The mean interview time was 38 min with a range of 17-67 min.
A total of five focus groups were held (three at site 1 and two at site 2). Seven clinical staff participated at site 1 (two doctors, a staff nurse, a pharmacist, an occupational therapist, physiotherapist and health care assistant) and five clinical staff at site 2 (An occupational therapist, a trainee nurse, a doctor, a health care assistant and a technical instructor). Five non-clinical staff participated at site 1 (three domestic staff, one tea server, one volunteer) and five nonclinical staff at site 2 (two volunteers, one ward clerk, two porters).
A further three staff at site 1 (two clinical, one non-clinical) and five staff at site 2 (three clinical, two non-clinical) provided informed consent but were unable to attend the focus group at the arranged time. The mean length of time for the focus groups was 47 min with a range of 28-57 min.
In total, we identified 44 risk factors from the coding of interview and focus group data; including 11 risk factors from the patient interviews, 13 risk factors from the focus groups with staff and 20 risk factors identified in both patient interviews and staff focus groups.

| Themes
Three themes were developed from the interview and focus group data.

Promoting independence and balancing risk
Promoting patient independence in the ward by encouraging patients to move around and do things for themselves, wherever possible, was identified by clinical staff as a key mechanism for reducing the development or exacerbation of MoF. However, clinical staff reported that promotion of independence needed to be balanced with some assessment of risk as encouragement of independence in some areas for example, general mobility, independent toileting could increase levels of risk in others for example, falls. Some clinical staff expressed fear of organizational repercussions for falls and this led to staff erring on the side of caution when it came to promoting independence.

Credibility
The extent to which an interpretation of data is representative of the experiences of participants Discussion of data and themes with co-author group (peer debriefing) to check that interpretations was representative of experiences. Co-author group are from multidisciplinary backgrounds including: Psychology (KH, FW), Nursing (SC, DC), Medicine (ET), Physiotherapy (AF). Study findings were also presented to a public and patient involvement group consisting of five members (recruited from a local older people's action and support group). Participants suggested that findings relating to ward culture and staff shortages resonated with their own experiences. The group was also glad to see isolation and lack of stimulation was included as they felt strongly that this was a key factor in older peoples decline during a hospital stay.

Transferability
The extent to which findings might be applied or generalized to other participants in similar contexts To inform readers judgements about transferability, we have included relevant contextual information about sites and participants in the findings.

Dependability
The extent to which a researcher's interpretation of data would be consistent if repeated We used NVivo software to provide a clear audit trail for the analysis.

Confirmability
The extent to which the findings of the study are free from bias Data were initially coded line-by-line using terminology which stayed close to the original data (and thus participant's experiences). In developing the themes, we actively explored atypical experiences to refine our interpretations. Two researchers coded a sample of transcripts (see method for further details) to ensure there was agreement on the coding of risk factors.
Everywhere I have worked falls has been a massive drive to reduce falls…even if someone maybe just been spotted being a little bit unsteady at one point… it's just kind of like, okay, don't get up on your own, press your buzzer and I think it's that kind of thing and again, it's just because of that fear… (clinical focus group, site 1) Patients also alluded to this issue when they indicated they felt the need to seek permission to move independently or go to the toilet by A further barrier to promoting independence was a lack of equipment e.g. walking frames to help patients to mobilize. Delays to accessing such equipment were sometimes also due to delays in accessing an assessment from a physiotherapist. However, some staff hinted at a misconception that a physiotherapist assessment was needed; P1: I think then it's that reliance on they need a physiotherapist.
P2: Mm, but then we can, rehab support workers can assess for walking aids but none of them do, do they?' (clinical focus group, site 1) Clinical staff also reported missed opportunities to promote independence when the assessment of risk level was not updated in a timely manner.
Yeah, it almost needs to be like reassessed and reassessed. Like they'll put a falls alarm on patients for like This was described by a carer and by staff as being problematic particularly for those with some existing level of frailty; with loss of independence and routine increasing the risk of losing function in activities of daily living. Patients and staff also reported that there was very little in the way of other activity for patients on the ward. Some patients expressed a sense of monotony, boredom and also isolation.
For example, the quotation below is from a patient who described feelings of isolation after they were unable to speak to their family: And I'd taken my mobile phone, but it wouldn't work… they were very busy, because that was the admissions unit and the nurse there did say "oh, don't worry, they will have informed your daughter you know, where you are". So, I knew that she would have been told, but it's not the same as being able to ring people…you lie there thinking, oh she'll be so worried… So, you know, after two or three days I did see people, but I did feel it was very isolating and that's not good. That's not good. However, one member of clinical staff also wondered whether their own processes for safely mobilizing patients may also exacerbate loss of confidence: Or like even if we're like mobilising patients and we're clinging on to them like that, it does nothing for anyone's confidence, you know, them thinking I need someone to be on my hip the whole time, rather than if you just take a step back and you know.
(clinical focus group, site 2) Figure 2 shows the theoretical framework we developed based on the modifiable risk factors identified in this qualitative study and the previous scoping review.

| Theoretical framework of modifiable risk factors for the development or exacerbation of MoF in the hospital setting
There was some overlap between the risk factors identified in the scoping review and the qualitative work, for example, pain, sleep disturbance. In addition to the risk factors identified in the scoping review, this qualitative study contributed a further 36 risk factors to the theoretical framework. Table 4 shows the additional risk factors identified by this qualitative study included in the framework. Table 4 shows that many of the risk factors identified by the qualitative study were related to linked care management risk factors such as ward culture, process of care and organizational factors.
In the theoretical framework we have categorized the risk factors into patient risk factor domains (e.g. mobility) and sub-domains (e.g. balance) and linked care management risk factor sub-domains, (e.g. poor flooring). The linked care management sub-domains were associated with the environment, ward culture and processes of care. We also theorized that some contextual risk factors had the potential to impact patient and linked care management risk factors for example, not having enough staff may lead to delays in answering call bells, being risk averse may hamper encouraging patients to be independent.

| DISCUSS ION
We  recent systematic review and meta-analysis suggested that this programme may also reduce the number of falls (Hshieh et al., 2018).
Organizations should take a balanced approach when encouraging falls prevention, given the risk for such initiatives (including requirements for falls reporting and the use of falls as a marker of care quality) to cause longer-term harm by restricting movement in hospitalized older adults (Growdon et al., 2017). A co-ordinated approach to managing MoF is needed to ensure that top-down initiatives or audits do not create organizational barriers to reducing risk.
A further challenge to reducing risk factors for MoF is the impact of low staffing levels which were reported to be problematic by both patients and staff. In this busy and understaffed context, By considering risk factors for MoF as a whole, it may also be possible to reduce overlapping care processes (e.g. multiple risk assessments) to maximize staff time and minimize inefficiencies caused by multiple care pathways for different MoF (e.g. duplicative paperwork). Redley and Raggatt (2017) found that standardized risk assessment forms for older people were often duplicated by different members of the MDT. Staff also reported a high level of administrative burden associated with completing such paperwork (Redley & Raggatt, 2017).
To reduce duplicative processes, it is important to clearly define the role of different MDT members in identifying and reducing risk for MoF. Nurses already play a significant role in risk screening and assessment procedures (Han et al., 2021;Redley & Raggatt, 2017), care quality and patient safety (Aiken et al., 2017) and therefore may be well placed to co-ordinate risk reduction for MoF. However, a need for further specialist or advanced nursing training to support leadership and competency in working with older people with frailty has been identified (Goldberg et al., 2016;Naughton et al., 2016). Further specialist training and competency frameworks may also be required for other healthcare professionals to facilitate risk reduction (Roller-Wirnsberger et al., 2020;Windhaber et al., 2018).
The theoretical framework developed as part of this study provides an overarching model of modifiable risk factors which may reduce the development or exacerbation of MoF in hospitalized older adults. The framework will aid the development of a comprehensive and targeted system of care designed to reduce overlapping care processes and address the risk factors identified. The theoretical framework indicates the importance of organizational and contextual factors suggesting that it may be useful to draw on existing theories for example. The Consolidated Framework for Implementation Research, Normalization Process Theory (Damschroder et al., 2009;Murray et al., 2010) to support the implementation of the intervention in complex healthcare systems. Work to prioritize the modifiable risk factors to be targeted as part of the system of care have been undertaken and is reported in separate paper.

| Limitations
Due to the limited time available for recruitment, we did not fully achieve our purposive sampling strategy. For example, the sample did not include patients from different ethnic groups and there were more female than male participants. The views and experiences of patients from these groups may be different from those who participated in this study. In addition, although we recruited from two NHS services, the services were in one geographical location and thus, the experiences of participants may not represent other areas of the country or countries outside of the United Kingdom. We did not note major differences between the sites in terms of patient or staff experiences or the risk factors identified, however, this was not explored formally in the analysis. The analysis was also limited in specifically exploring other nuances of the data including the impact of reason for admission on patient experience. Lastly, it is important to note that this work was undertaken prior to the COVID-19 pandemic; which is likely to have had a significant impact on the way in which care for hospitalized older adults is organized and delivered.

| CON CLUS ION
To reduce the risk of functional decline in hospitalized older people, it is necessary to have a comprehensive understanding of modifiable risk factors which may contribute to the development of exacerbation of MoF. It is also important to recognize the complexity of the healthcare systems in which risk is managed and to understand the ways in which the process or organization of hospital care contributes to increasing or mitigating risk for MoF. The theoretical framework developed in this study will act as a starting point for developing a novel system of care to reduce the risk of loss of independence in hospitalized older adults. The framework will be subject to further validation and development as part of this work. A future programme of research will be undertaken to refine and evaluate the effectiveness of the developed system of care.

ACK N OWLED G EM ENTS
The authors are grateful for the funding provided by the National Institute for Health Research (NIHR). The authors wish to thank the ward staff, patients and carer who participated in this study and the organizations and clinical research network staff who facilitated recruitment. The authors also wish to thank the OPTIMISE programme team for their contribution to this project.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the authors.

AUTH O R CO NTR I B UTI O N S
This study was conceived of and designed by Elizabeth Teale, David

PE E R R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15120.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.